Introduction: Nursing Homes play a crucial role in providing care and support to residents. Effective assessments and care planning are essential to meet the diverse needs of residents and ensure their well-being. The following is a review of various aspects of assessments and care planning, highlighting best practices and key considerations.
Resident Needs Assessment: Assessing a resident’s needs involves understanding how these needs affect their well-being and daily activities. It is important to promote residents’ interests and independence, recognize the effects of loneliness, and respect their dignity. Key areas for assessment include health, psychosocial, functional, nutritional, and activity status; personal care and other needs; health needs; the capability of self-preservation; specific social and activity interests; and discharge planning . Various categories for patient assessment include admission nursing assessment, psychosocial, history and physical, mental health/psych, incontinence, bed rails, drug therapy/meds, fall risk, functional status, pain, skin, nutrition, dental, and wound.
Minimum Data Set (MDS): The Resident Assessment Instrument (RAI), commonly known as the MDS, is a federally mandated tool used for clinical assessments in Medicare or Medicaid certified nursing homes. It provides a comprehensive assessment of each resident’s functional capabilities and helps identify health problems. Section V of the MDS provides guidance on key issues identified in comprehensive MDS and directs staff to evaluate triggered areas. The CAA covers the majority of care areas problematic to residents, totaling 20 CAAs.
Quality Measures: Quality measures for short-stay and long-stay residents include various metrics such as hospitalizations, medication needs, falls, pressure ulcers, urinary tract infections, catheter insertions, mobility, assistance with daily activities, and vaccination status.
Care Plans in Nursing Homes: Care plans are essential for strategically approaching and streamlining the nursing process. They enable effective communication within the nursing team and ensure that residents’ needs are met through comprehensive and individualized care plans. A nursing care plan documents the process of identifying a resident’s needs and facilitating holistic care. It ensures collaboration among nurses, residents, and other healthcare providers. Key components of a care plan include assessments, diagnoses, outcomes and planning, implementation, and evaluation.
Common deficiencies related to resident assessments include issues with timely determination of significant changes, quarterly review assessments, maintaining all resident assessments, automated data processing requirements, accuracy of assessments, and the requirement for a registered nurse to conduct or coordinate each assessment.
Conclusion: Effective assessments and care planning are vital for ensuring the well-being of residents in nursing homes. By adhering to best practices and addressing common deficiencies, nursing homes can provide high-quality care that meets the diverse needs of their residents.
